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Resource Procedure - Content 4.6

An action that is performed on a patient. This can be a physical 'thing' like an operation, or less invasive like counseling or hypnotherapy.

The resource name as it appears in a RESTful URL is [root]/procedure/

An Act whose immediate and primary outcome (post-condition) is the alteration of the physical condition of the subject. Used to record the details of procedures performed on a patient. This includes surgical procedures, diagnostic procedures, endoscopic procedures, biopsies. It excludes things for which there are specific resources, such as immunizations, drug administrations

Resource Content 4.6.1

Procedure (Resource)The person on whom the procedure was performedsubject : Resource(Patient) 1..1The specific procedure that is performedtype : CodeableConcept 0..1Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesionbodySite : CodeableConcept 0..*The reason why the procedure was performed. This may be due to a Condition, may be coded entity of some type, or may simply be present as textindication : string 0..1The dates over which the period was performed. Allows a period to support complex procedures that span more that one date, and also allows for the length of the procedure to be captureddate : Period 0..1The encounter during which the procedure was performedencounter : Resource(Encounter) 0..1What was the outcome of the procedure - did it resolve reasons why the procedure was performed?outcome : string 0..1This could be a histology result. There could potentially be multiple reports - e.g. if this was a procedure that made multiple biopsiesreport : Resource(DiagnosticReport) 0..*Any complications that occurred during the procedure, or in the immediate post-operative period. These are generally tracked separately from the notes, which typically will describe the procedure itself rather than any 'post procedure' issuescomplication : string 0..1If the procedure required specific follow up - e.g. removal of sutures. The followup may be represented as a simple note, or potentially could be more complex in which case the CarePlan resource can be usedfollowUp : string 0..1Any other notes about the procedure - e.g. the operative notesnotes : string 0..1PerformerThe practitioner who was involved in the procedureperson : Resource(Practitioner) 0..1E.g. surgeon, anaethetist, endoscopistrole : CodeableConcept 0..1RelatedItemThe nature of the relationshiptype : code 0..1 <<The nature of the relationship with this procedureProcedureRelationshipType>>The related item - e.g. a proceduretarget : Resource(Procedure|MedicationPrescription) 0..1Limited to 'real' people rather than equipmentperformer0..*Procedures may be related to other items such as procedures or medications. For example treating wound dehiscence following a previous procedurerelatedItem0..* 
<Procedure xmlns="http://hl7.org/fhir">
 <!-- from Resource: extension, narrative, and contained -->
 <subject><!-- 1..1 Resource(Patient) Subject of this procedure § --></subject>
 <type><!-- 0..1 CodeableConcept Identification of the procedure § --></type>
 <bodySite><!-- 0..* CodeableConcept Precise location details § --></bodySite>
 <indication value="[string]"/><!-- 0..1 Indications for the procedure § -->
 <performer>  <!-- 0..* The people who performed the procedure § -->
  <person><!-- 0..1 Resource(Practitioner) The reference to the practitioner § --></person>
  <role><!-- 0..1 CodeableConcept The role the person was in § --></role>
 </performer>
 <date><!-- 0..1 Period The date the procedure was performed § --></date>
 <encounter><!-- 0..1 Resource(Encounter) The encounter during which the procedure was performed § --></encounter>
 <outcome value="[string]"/><!-- 0..1 Outcome of the procedure § -->
 <report><!-- 0..* Resource(DiagnosticReport) Any report that results from the procedure --></report>
 <complication value="[string]"/><!-- 0..1 Complications -->
 <followUp value="[string]"/><!-- 0..1 Instructions for follow up -->
 <relatedItem>  <!-- 0..* A procedure that is related to this one -->
  <type value="[code]"/><!-- 0..1 caused-by | caused -->
  <target><!-- 0..1 Resource(Procedure|MedicationPrescription) The related item - e.g. a procedure --></target>
 </relatedItem>
 <notes value="[string]"/><!-- 0..1 Procedure notes -->
</Procedure>

Alternate definitions: Schema/Schematron, Resource Profile

Terminology Bindings 4.6.1.1

PathDefinitionTypeReference
Procedure.relatedItem.type The nature of the relationship with this procedureFixedhttp://hl7.org/fhir/procedure-relationship-type

Questions

Search Parameters 4.6.2

Search Parameters for RESTful searches. The standard parameters also apply. See Searching for more information.

Name / TypeDescriptionPaths
_id : tokenThe logical resource id associated with the resource (must be supported by all servers)
date : datethe date the procedure was performed onProcedure.date
subject : referenceThe identity of a patient to list procedures forProcedure.subject
type : tokentype of procedureProcedure.type